Treatments

Treatment of acid reflux

People with Barrett’s Oesophagus often have bad acid reflux but, curiously, may have very few symptoms. The treatment for reflux in people with Barrett’s Oesophagus is the same as for people who do not have Barrett’s.

There are three approaches:

1. Things you can do for yourself:

Avoid eating large meals and avoid eating within two hours of going to bed. The following foods tend to make reflux symptoms worse: chocolate, coffee, alcohol, fizzy drinks, spicy foods, citrus. However, lifestyle changes will only help about one in five who have the condition.

2. Drugs

Antacids immediately neutralise the acid that has already been made. They may be either liquids or tablets and should be taken as soon as you get symptoms. Rennies and Tums, and most of the other medicines which you can buy over the counter, work in this way. Alginates also contain antacids but, in addition, have a special ingredient which coats the lining of the stomach and oesophagus. This barrier prevents the acid from breaching the area where it would otherwise cause damage. Gaviscon and Gastrocote are examples of this class of medicine. Acid suppression tablets work to stop acid being made before it can cause damage.

There are two types: histamine receptor antagonists like ranitidine (Zantac) and proton pump inhibitors (PPIs) such as omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole. These PPIs are far more effective at controlling acid reflux. Most patients with Barrett’s Oesophagus will be taking one of these routinely.

3. Surgery

Fundoplication surgery is a treatment which aims to restore the normal valve at the lower end of the oesophagus which often does not work properly in people with Barrett’s Oesophagus. This treatment is often carried out as a keyhole operation. You would only need to stay in hospital for one or two days, although it usually takes four weeks to recover completely from the operation. Fundoplication surgery is successful in stopping acid reflux in over 80% of patients. Side effects do occur in a small proportion of patients, so before agreeing to have surgery it is important to discuss these with the surgeon. Things which can trouble people after surgery include bloating of the abdomen, difficulty in swallowing and, rarely, severe diarrhoea. Some surgeons advocate a modified procedure to reconstruct the valve which virtually eliminates these side effects whilst preserving reflux correction.

Everyone with acid reflux should try to make lifestyle changes. Often, simple changes to when and what they eat will make people feel very much better. Many people will still need to take drugs.
People with frequent or severe symptoms should consider taking acid suppression tablets to try and prevent complications of acid reflux such as scarring of the oesophagus. Surgery is usually reserved for people who do not respond well to lifestyle changes and drug therapy.

Treatments to prevent cancer

Since the vast majority of patients with Barrett’s Oesophagus do not get cancer, the usual practice in the United Kingdom is not to attempt to remove the Barrett’s cells. Treatment is usually only offered if the cells look as though they are starting to change and the risk of getting cancer starts to rise. Although in theory, exposure to acid and bile may make cells more likely to turn cancerous, there is no clear evidence that aggressive suppression of acid reflux does actually reduce the risk of cancer. Decisions about these treatments should generally be made on the basis of symptoms.

Dysplasia: This word is derived from the Greek meaning roughly “bad formation”. It is used to describe an abnormality within the tissue where the tissue changes and may in some cases progress to cancer.

Dysplasia is the earliest form of pre-cancerous change that can be recognised and may be low grade or high grade, the latter representing a more advanced progression towards cancer.

Treatment for people with low grade dysplasia

The risk of people with confirmed low grade dysplasia getting cancer is around 12%. For this reason most doctors do recommend treatment for this condition (either EMR if nodular or radiofrequency ablation, if not nodular) if LGD is confirmed on two consecutive endoscopies. 6 monthly surveillance is no longer recommended unless in specific circumstances.This is the current guideline of the British Society of Gastroenterology.

Treatment for people with high grade dysplasia

Half of all patients with high grade dysplasia will develop cancer in around five years. All people with high grade dysplasia should be referred to a specialist centre where their case is discussed by a multi-disciplinary team of doctors and where the doctors perform minimally invasive but complex treatments frequently. All these treatments aim to remove the dysplasia.

In addition, they may aim to replace the red, Barrett’s Oesophagus, with normal pink (squamous) lining.

Radiofrequency ablation

This is now the recommended treatment for Barrett’s with high grade dysplasia, and has replaced major surgery (oesophagectomy) as the treatment of choice for dysplasia. However, in a small number of cases where early cancerous change has already occurred, resection may still be necessary. It uses electrical current produced by radio waves to destroy the dysplasia and is performed during an endoscopy.You will be given a sedative to make you sleepy. A probe will be used to deliver the radio waves to the affected parts. The procedure takes about 45 minutes. Treating circumferential and/or long Barrett’s using a balloon catheter. Some people return to normal immediately after treatment, most have mild pain easily controlled with simple pain killers for a few days; however, some may have chest pain and nausea particularly when they eat, for up to three weeks after treatment. A few people (around 1 in 20) suffer scarring of the oesophagus, but this can normally be treated by another endoscopy. This treatment is usually repeated three or four times at intervals of two to three months until not only the dysplasia, but also the entire Barrett’s oesophagus has been removed.

Treating a small area of disease using a focal catheter. After treatment patients have to continue regular surveillance as before, usually every 6 months and then every year. Although radiofrequency ablation is safer and has fewer side effects than major surgery, the disadvantage is that it involves many endoscopies and the need for continued surveillance.

Endoscopic Mucosal Resection

Some patients with high grade dysplasia have a visible nodule in their oesophagus. It is relatively straightforward to remove the nodule during endoscopy. The procedure takes around 30-45 minutes and you can usually go home the same day. If you have this procedure you will be given a sedative to make you slightly sleepy. Most people can eat and drink normally afterwards. In about one in ten people there may be minor bleeding, and more serious bleeding in one in 50 people. Endoscopic mucosal resection is a particularly useful test if the diagnosis is not clear because the removed nodule can be sent to the laboratory to be checked by the pathologist. In this situation, it serves as both a diagnostic test and a treatment.

In a small number of cases, histology may show that early cancerous change has occurred, in which case, resection may be necessary. Mucosal resection does not aim to remove the Barrett’s cells completely; it cannot remove large sections of affected oesophagus without causing scarring and difficulty in swallowing; however, usually patients go on to have radiofrequency ablation to complete treatment, as described above. Research is going on all the time into new ways to treat Barrett’s oesophagus. New studies are being published regularly. Please speak to your specialist about the current state of knowledge regarding the treatments available.